CQC report explained · a residential care home
What the CQC found at 167 Lodge Hill
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found people were not always protected from avoidable harm because of problems with a water leak, an unsafe radiator and unclean areas. Medicines, safeguarding arrangements, recruitment and risk plans were otherwise found to be managed safely.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had the training and skills needed, and people were supported with nutrition, healthcare, communication and lawful consent arrangements.
- Caring?
- Good
- Staff were kind, attentive and respectful. People were offered choices, involved in decisions where possible, and supported with their privacy, dignity, independence and diverse needs.
- Responsive?
- Good
- Care plans reflected people's needs, preferences and communication methods. People had access to activities, relatives, community facilities and a complaints process.
- Well-led?
- Good
- The service had audits, staff meetings and systems for gathering feedback and improving care. There was no registered manager in post at the inspection, but an experienced manager from another service was managing the home and had applied to become registered manager.
What inspectors found, October 2019
167 Lodge Hill was rated Good overall, but inspectors found the home was not always safe and rated Safe Requires Improvement.
This was an unannounced inspection on 25 July 2019. One inspector spoke with relatives, staff and healthcare professionals, observed care, and reviewed care, medicines, staffing and management records.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. Inspectors found kind care, suitable training, support with food and healthcare, personalised activities, and involvement of people and relatives.
Safe was rated Requires Improvement. Inspectors found a water leak, an unsafe radiator with sharp edges, and stains on floors and walls. The manager removed loose metal rods immediately and said refurbishment work was planned. The overall Good rating should therefore be read alongside the safety concerns.
Kind and respectful care
Inspectors saw positive interactions. Staff supported people's choices, privacy, dignity and independence.
“People were supported by staff that were kind and caring towards them.” from the report
Skilled staff
Staff had completed induction, training, supervision and appraisals. Relatives and professionals said staff understood people's needs.
“Relatives and professionals told us staff had the knowledge and skills to support people's needs.” from the report
Personalised support
Care plans included people's needs, preferences, communication methods and changing requirements. Staff knew people well.
“Each person had a care plan which provided staff with guidance on how their needs should be met.” from the report
Activities and community access
People took part in activities suited to them and were supported to use local facilities and maintain important relationships.
“People were supported to follow their interests and participated in activities which were socially relevant and suitable to them.” from the report
Safe medicines support
Medicines were stored, given and recorded safely. Staff had completed medicines training and practical assessments.
“The support people received with their medicines was recorded on a medicines administration record (MAR) and this was completed without any gaps.” from the report
Unsafe parts of the building
seriousA water leak affected the living room and a hallway radiator had sharp edges and loose metal rods. The loose rods were removed during the inspection, but other repairs were still being pursued.
“People were not always protected from the risk of avoidable harm.” from the report
Cleanliness and condition
needs fixingInspectors saw stains on floors and walls. The home looked tired and needed refurbishment, although plans were in place to replace flooring and redecorate.
“Not all areas of the home appeared clean.” from the report
Staffing did not match the plan
needs fixingThe number of staff on duty did not match the planned number. Staff said there were enough people to meet needs, and inspectors saw people attended to promptly.
“The number of staff on shift did not match the number of staff planned for.” from the report
- 01Has the water leak been fully repaired, and has the ceiling been fixed?
- 02Has the unsafe hallway radiator been repaired or replaced?
- 03Have the flooring, stains and tired areas of the home been refurbished since the inspection?
- 04How do you make sure the number of staff on each shift matches the assessed needs and staffing plan?
- 05Who is currently the registered manager, and what happened with the application mentioned in the report?
This was an unannounced planned inspection covering all five CQC questions, including both the care provided and the home environment. This explanation was written from the published report of 16 October 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2017
Rated Good; inspectors found safe, kind and well-organised care, but a required DoLS notification had not been sent on time.
This was an unannounced comprehensive inspection on 28 and 29 December 2016. One inspector spoke with a person using the service, a relative, five staff and the registered manager. Records for four people and four staff were checked, along with medicines, complaints, incidents and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable risk assessments, safe medicines practice and clean premises. Staff were trained and supported, and people received help with food, healthcare, activities and communication.
People were treated with kindness and respect. Care plans were personalised and up to date. Relatives and healthcare professionals gave positive feedback, and the home had a calm and friendly atmosphere.
The previous inspection found a breach involving legal requirements for people who could not consent. Inspectors found this had been corrected. However, the home had not told the CQC about some DoLS authorisations when required. The notifications were sent during the inspection, and inspectors found no negative impact on people.
Kind and respectful care
Staff used positive communication and supported people's privacy, dignity, choices and independence.
“Staff treated people with respect and kindness.” from the report
Personalised care
Care plans included people's histories, preferences, health needs and the support they could manage themselves. Inspectors found all four care plans reviewed were up to date.
“These contained information about their personal life and social history, their physical and mental health needs, allergies, family and friends, preferred activities and contact details of health and social care professionals.” from the report
Support with health and activities
People were helped to attend healthcare appointments and take part in activities suited to their interests and social needs.
“Staff supported people to follow their interests and take part in activities they enjoyed.” from the report
Positive leadership
Inspectors found a calm, friendly culture with regular meetings and quality checks used to make improvements.
“The service had a positive culture, where people and staff felt the service cared about their opinions and included them in decisions.” from the report
DoLS notifications were late
needs fixingThe provider had not notified the CQC about some Deprivation of Liberty Safeguards authorisations as required. The notifications were sent during the inspection, and inspectors found no negative impact on people.
“We found that the provider had not notified to the Care Quality Commission (CQC) as required, about the authorisations under the Deprivation of Liberty Safeguards (DoLS)” from the report
- 01How do you now check that all DoLS authorisations are notified to the CQC within the required timescale?
- 02How will you assess and update my relative's risk assessments if their needs change?
- 03What activities would be available for my relative based on their interests and communication needs?
- 04How would you involve me and my relative in care plan reviews and decisions about care?
- 05How do you make sure staffing levels increase when someone needs extra support for appointments or activities?
This was an unannounced comprehensive inspection covering all five CQC questions; the previous breach about consent and mental capacity had been checked and was found to be corrected. This explanation was written from the published report of 25 January 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 167 Lodge Hill
3 rated inspections over 4 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 16 March 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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